HOURLY (NON-EXEMPT) EMPLOYEE PAYROLL ADJUSTMENT FORM
Employee Name
Employing Department
CWID
Pos #
OR
Index
Name of Supervisor
Fund
Org
Program
DATES AND TIMES OF HOURS WORKED TO BE PAID IN THE ADJUSTMENT
(Hours may be shown in 15 minute intervals ONLY)
Date
In
Out
In
Out
In
Out
Hours
Date
In
Out
In
Out
Total Hours to be Paid
Date
I certify that I have worked the hours shown above
Employee's Signature
Justification for Adjustment (to be completed by the supervisor):
For Payroll:
Supervisor's Signature
Date
Dean/Dept Head Signature
Date
Vice President Signature
Date
Hours Worked:
Rate of Pay:
Gross Earnings:
Earnings Code Used: _______________
In
Out
Hours